Effective implementation of a protocol on initial stabilization of preterm neonates delivered at less than 32 weeks gestation through a simulation programme in a District General Hospital *

Background: Effective initial stabilization of preterm neonates in the initial 60 minutes of life (termed neonatal golden hour) helps minimize complications such as intraventricular haemorrhage and chronic lung disease and leads to improved prognosis. Effective resuscitation, respiratory support, maintaining normal temperature and blood sugar, timely parenteral nutrition, timely treatment of sepsis and a completed admission within 60 minutes of delivery are identified as key components of the golden hour. High intensity and multitude of interventions necessary for initial stabilization, performed by a staff that lacks uniform training make golden hour a challenging task. A protocol can provide a care pathway on the essential steps of the golden hour. Simulationbased learning to practise the protocol has been identified as way to create a cohesive team. Objectives: To evaluate effective implementation of a protocol on initial stabilization of preterm neonates delivered at less than 32 weeks gestation through a simulation programme. Study design: Prospective study Method: The extent to which the key components of neonatal golden hour were achieved before and after implementation of the protocol were assessed using a checklist. Results: In the post-protocol group a significant increase was seen in the number of infants resuscitated with optimal preparation and attended _________________________________________ Consultant Paediatrician, District General Hospital, Hambantota, Medical Officer, Lady Ridgeway Hospital for Children, Colombo, Medical Officer, District General Hospital, Hambantota. *Correspondence:durgaherath@gmail.com (Received on 05 January 2015: Accepted after revision on 19 February 2015) The authors declare that there are no conflicts of interest. Personal funding was used for the project. Open Access Article published under the Creative Commons Attribution CC-BY License. by a senior member of staff (p<0.05), the number of infants who received intravenous glucose infusion and antibiotics (p<0.01), the number of infants with blood sugar more than 2.6mmol/l in 1 hour (p<0.05) and the number of infants with completed admission within 1 hour (p<0.01). There was a statistically significant difference in adherence to thermo-protective measures during stabilization (p<0.01), and the number of neonates with temperature above 36.5C on admission (p<0.01) in the post-protocol group. Conclusions: Implementation of the golden hour protocol through a simulation programme can significantly improve the stabilization of infants delivered at less than 32 weeks gestation. DOI: http://dx.doi.org/10.4038/sljch.v45i4. 8183 (


Background
Preterm birth is a leading cause of neonatal mortality and morbidity.Poor outcomes result from sepsis, intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC), chronic lung disease (CLD) and retinopathy of prematurity (ROP).Studies have shown that effective initial stabilization aimed to complete within 60 minutes of birth help in minimizing these complications and lead to improved outcomes.The first 60 minutes after birth is hence named neonatal golden hour [1][2][3][4][5] .The following are identified as the key components of the neonatal golden hour 5 : 1. Resuscitation and respiratory support 2. Maintaining normal temperature and blood sugar 3. Timely parenteral nutrition administration 4. Rapid treatment of sepsis

Completed admission within 60 minutes of delivery
To achieve all these goals the team members must act in a coordinated manner and have assigned roles.The high intensity and dynamic situation in stabilizing neonates and the multitude of tasks involved make it a difficult task.Lack of uniformity of skills and knowledge of the staff involved make it difficult to offer consistent organized care.A protocol can provide the "road map" on essential steps of the golden hour.Hence each patient is cared for in the same process, allowing for fewer mistakes and better outcomes.
Use of simulation-based learning to practise the protocol in a safe environment has been identified as a way to create a cohesive team 6,7 .Simulation allows the team to utilize the same equipment, practise teamwork and streamline the process in a realistic setting prior to use on a patient.Through facilitated debriefing, team members identify errors as well as communication opportunities and make corrections to their practice.

Objectives
The primary objective was to evaluate effective implementation of a protocol on initial stabilization of preterm neonates delivered at less than 32 weeks gestation through a simulation programme.Specific objectives were to compare the extent to which key components of the neonatal golden hour were achieved before and after introduction of the protocol.1).

Method
The protocol was introduced to medical, nursing and minor staff of neonatal unit (NNU), General Hospital Hambantota in the form of a lecture.The lecture comprised the special requirements of preterm neonates, key areas of neonatal golden hour stabilization, behavioural skills such as assigning roles, effective communication, delegation and call for help.A questionnaire with multiple choice questions at the end of the lecture was used to ensure that key areas of stabilization were understood by participants.This was followed by practical training sessions comprising a scenario teaching (using mannequins) of an extreme preterm extreme low birth weight neonate.Each staff member was given the opportunity to resuscitate and stabilize the preterm neonate followed by a debriefing session.The above areas of neonatal stabilization were assessed in the neonates born in post-protocol time period using a checklist completed by one of the researchers.
Statistical analysis was conducted using SPSS version 16.Statistical significance between preand post-protocol observations was assessed using Chi-Square test for discrete categorical variables and ANOVA for continuous variables.A p value less than 0.05 was considered significant.Ethical approval was obtained from the ethical review committee of the Sri Lanka College of Paediatricians

Results
Data for a total of 122 preterm infants were reviewed, 58 (47.5%) in the pre-protocol group and 64 (52.4%) in the post-protocol group.Three neonates in the pre-protocol group and 2 neonates in the post-protocol group were not included as parental consent was not obtained.There was no significant difference in demographic data between the two groups as shown in Table 1.Data for resuscitation and respiratory support are shown in Table 2. Data for maintaining normal temperature and blood sugar are shown in Table 3. Data for administration of dextrose, antibiotics and vitamin K are shown in Table 4.

Discussion
Our study demonstrated significant improvement in preparation for resuscitation, higher rates of early surfactant administration and better oxygen saturation at 10 minutes following implementation of the protocol.It showed better adherence to thermo-protection resulting in better axillary temperature on admission.Further, it showed improved rates of IV fluid and antibiotic administration, better random blood sugar within 1 hour of birth and higher rates of completing admission within 1 hour.
Several studies have been done on implementation of the protocol on golden hour as part of quality improvement projects.Ashmede et al. demonstrated improved surfactant administration, dextrose and aminoacid infusion, body temperature at admission, odds of developing chronic lung disease, and odds of developing ROP following implementation of the project 11 .Wallingford B et al concentrated extensively on strategies to prevent CLD, thermoregulation and team work 3 .This study showed increasing compliance with the goldenhour practices and decreased incidence of CLD.Finer et al reported improved resuscitation of preterm neonates following use of video recordings to look at the use of oxygen, effectiveness of bag and mask ventilation, intubation in the delivery area and communication among team members 12 .These studies have used lectures, posters, emails and training sessions to introduce the protocol.None mention the educational background of the staff involved.None have studied the sustainability of improvement achieved.Our study concentrated on achievement of all key components of neonatal golden hour described by Doyle and Vermont Oxford Network.The principal method of training was a simulation programme where every staff member had the opportunity to be trained and evaluated.Effective resuscitation needs optimal preparation, availability of appropriate senior help and adhering to standard resuscitation guidelines.
Limitations of the study include non-assessment of secondary outcomes such as CLD, ROP and IVH and non-evaluation of the sustainability of results obtained.

Conclusion
Implementation of the Golden Hour Protocol through a simulation programme can significantly improve the stabilization of infants delivered at less than 32 weeks gestation.

Table 1 : Protocol on early stabilization of preterm neonates 32 weeks or less Preparation/ duties of doctors Preparation/ duties of nurses
SedationEnsure antibiotics and Vitamin K given

Table 1 :
Demographic data